SAINT STEPHEN’S EPISCOPAL CHURCH

CHURCH SCHOOL REGISTRATION - 2006-2007 - NURSERY THROUGH GRADE 9 Please fill out one form per family

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Father’s Name: __________________________________ Telephone: _____________

Mother’s Name:__________________________________ Telephone:_____________

Address: ____________________________________________________________________________________________________________________________________________________

Parent and/or child(ren) E-Mail Address(es): ______________________________________________________________________

1) Child’s Full Name: _________________________________Date of Birth: ____/____/____ Age: ____

Please circle appropriate class: N 3’S 4’S K 1 2 3 4 5 6 7 8 9 Sex: M / F

Receives Communion? Yes / No Confirmed? Yes / No

Explain any conditions which may limit activity or any we should be aware of: (Additional space on back)

____________

2) Child’s Full Name: _________________________________ Date of Birth: ____/____/____ Age: ____

Please circle appropriate class: N 3’S 4’S K 1 2 3 4 5 6 7 8 9 Sex: M / F

Receives Communion? Yes / No Confirmed? Yes / No

Explain any conditions which may limit activity, or any we should be aware of: (Additional space on back)

____________

3) Child’s Full Name: _________________________________ Date of Birth: ____/____/____ Age: ____

Please circle appropriate class: N 3’S 4’S K 1 2 3 4 5 6 7 8 9 Sex: M / F

Receives Communion? Yes / No Confirmed? Yes / No

Explain any conditions which may limit activity, or any we should be aware of: (Additional space on back)

________

I (We) _______________________ hereby authorize the teachers/staff of St. Stephen’s Church School to act on my (our) behalf if emergency treatment is needed for my (our) child.

Signature of Parent/Guardian: ____________________________________Date____________

Please return this form to the Church Office